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Achalasia May Mimic Anorexia Nervosa, Compulsive Eating Disorder, and Obesity Problems

Key Words: Achalasia • Anorexia Nervosa • Eating Disorders

TO THE EDITOR: In the past, physicians did exhaustive medical evaluation in the pursuit of organic pathology for patients with eating disorders.¹ Judging from the literature, the incidence of anorexia nervosa increased over the past century until the 1970s,² and now, physicians have an increased awareness of it and find it easier to diagnose. The consequence is the increasing failure to notice organic pathology in patients who have a history of eating disorders.³ We report the case of a young man referred for evaluation of anorexia nervosa, who, after investigation, turned out to be suffering from achalasia.

Case Report

Mr. A, a 24-year-old Caucasian patient, had a history of vomiting and a 60-kg weight loss over the preceding 7 months (Body Mass Index [BMI] at admission: 17.6). He had suffered from asthma since his childhood. When he was 18, his weight was 96 kg, and he described, from the age of 18 to age 23, compulsive eating behavior with binging, but not purging, and use of laxatives or diuretics. Six months before the beginning of symptoms mimicking anorexia nervosa, his best friend had died in an automobile accident. At this time, he was 120 kg (BMI: 37). He is still very affected by this accident.

When he was admitted, his clinical evaluation was normal except for a low potassium level (2.7 mmol/liter) and frequent complaints about "a lump in the throat." His parents believed that he practiced self-induced vomiting, although he denied this. Frequently, the parents would force him to eat and wait with him during some time after meals to make sure that he did not vomit, because the boy had uncontrollable vomiting after every meal. The early symptoms were heartburn and dysphagia. The patient stated that he often had chest pain after food or liquid intake. Body-image distortions were absent, but the intention to lose weight was present at the early stage. He denied self-induced vomiting, but did note that vomiting improved his symptoms and that he was preoccupied by food, without any rituals. The patient did not use laxatives or diuretics.

Family history revealed that the mother had been diagnosed as having morbid obesity and had had bariatric surgery. She was currently receiving psychotherapy for depression.

For his general practitioner, the conflict about food and autonomy between Mr. A and his parents was thought to have contributed to the illness.

An upper gastrointestinal radiographic series revealed a grossly dilated esophagus and a tight esophageal sphincter compatible with the diagnosis of achalasia. Pneumatic dilatation of the lower esophageal sphincter was successful, and the patient has gained weight since that time. He is still under psychotherapeutic treatment for his family and behavioral problems.

Discussion

Dysphagia is the initial and main clinical feature of achalasia. Often, several years elapse before the disease is diagnosed, and, during this time, other symptoms, such as vomiting and weight loss, are common.⁴ During this period, achalasia can be mistaken for anorexia nervosa. Moreover, previous obesity of the patient is of interest, since an association between morbid obesity and achalasia has been described.⁵ This, along with episodes of asthma,⁶ leads us to believe that the patient probably had his achalasia before his symptoms of dysphagia.

Nevertheless, differential diagnosis between achalasia and anorexia nervosa is not always obvious. First, it has been reported that esophageal motor disorders are common in patients with a diagnosis of primary anorexia nervosa.⁷ For example, patients with eating disorders frequently have gastric emptying abnormalities causing bloating, postprandial fullness, and vomiting. These symptoms usually improve with refeeding, but sometimes promotility agents may be necessary.⁸ Second, willful avoidance of food and spontaneous or self-induced vomiting have been reported in patients with achalasia.^9–11 Thus, gastrointestinal disorders are common in eating-disorder patients, and many gastrointestinal diseases sometimes present like eating disorders. But, for Rosenzweig and Traube,¹² errors in diagnosis are related to delay in obtaining appropriate investigations or misinterpretation of their results. Abell and Werkman¹³ suggest that a careful clinical history can localize gastrointestinal motility disorders, and they suggest appropriate diagnostic tests.¹³ They differentiate between two groups of symptoms: first, dysphagia, odynophagia, heartburn, and reflux have esophageal origins and occur in achalasia. The appropriate diagnostic tests in this case are barium-swallow endoscopy¹⁰ and esophageal motility studies (esophageal manometry or scintigraphy). The second group of symptoms includes nausea, vomiting, anorexia, bloating, and abdominal pain, which are symptoms of motor disorders of the stomach and small intestine.

In summary, the exclusion of organic disease must be a priority, even if a psychotherapeutic intervention may be needed in the global care of this group of patients.

REFERENCES

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